<html><head>
        <title>Formulir Data Pindah Pergi Penduduk</title>
        <link href="<?php echo base_url('assets/css/formpindahpergi.css') ?>" rel="stylesheet" type="text/css" />
        <link href="<?php echo base_url('assets/js/jquery-ui.css'); ?>" rel="stylesheet" type="text/css" />
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-1.9.1.js'); ?>"></script>
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-ui.js'); ?>"></script>  
        <script type="text/javascript">
            $(function() {
                $("#tanggal_pergi").datepicker({changeMonth: true, changeYear: true});
            });
        </script>               
    </head>
    <body>
        <form action="<?php echo base_url('pindah_pergi/tambah'); ?>" method="post">
            <table width="90%" border="0" align="center">
                <tr>
                    <td colspan="6" class="trheader">Formulir Data Pindah Pergi Penduduk</td>
                </tr>
                <tr>
                    <td width="289">No.  Formulir Pindah</td>
                    <td colspan="5"><input type="text" name="nomor" id="nomor" class="textinput" placeholder=""/></td>
                </tr>
                <tr>
                    <td>Kategori Pindah</td>
                    <td colspan="5"><select name="idkat_pindah" id="idkat_pindah" class="list">
                            <?php
                            if (isset($kat_pindah)) {
                                foreach ($kat_pindah->result() as $data_kat_pindah) {
                                    echo '<option value="' . $data_kat_pindah->idkat_pindah . '">' . $data_kat_pindah->kat_pindah . '</option>';
                                }
                            }
                            ?>
                        </select></td>
                </tr>
                <tr>
                    <td colspan="6" class="jeda">Data Daerah Asal</td>
                </tr>
                <tr>
                    <td>NIK Pemohon</td>
                    <td colspan="2"><input type="text" name="nik" id="nik" class="textinput" placeholder="3501061411910002"/></td>
                    <td colspan="3">&nbsp;</td>
                </tr>
                <tr>
                    <td>No. KK</td>
                    <td colspan="2"><input type="text" name="no_kk" id="no_kk" class="textinput" placeholder="3501062001053536"/></td>
                    <td width="356">&nbsp;</td>
                    <td width="6" colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="6" class="jeda">Data Kepindahan</td>
                </tr>
                <tr>
                    <td>Alasan Pindah</td>
                    <td colspan="2"><select name="alasan" id="alasan" class="list">
                            <option value="Pekerjaan">Pekerjaan</option>
                            <option value="Pendidikan">Pendidikan</option>
                            <option value="Keamanan">Keamanan</option>
                            <option value="Kesehatan">Kesehatan</option>
                            <option value="Perumahan">Perumahan</option>
                            <option value="Keluarga">Keluarga</option>
                            <option value="Lainnya">Lainnya</option>
                        </select></td>
                    <td>&nbsp;</td>
                </tr>
                <tr>
                    <td>Alamat Tujuan</td>
                    <td colspan="4"><textarea name="alamat_tujuan" class="textaa" id="alamat_tujuan" rows="2" cols="51" placeholder="Jl. Gang. Blok. "></textarea></td>
                </tr>
                <tr>
                    <td>Desa</td>
                    <td colspan="1"><input type="text" name="desa_tujuan" id="desa_tujuan" class="textinput" placeholder="Desa tujuan"/></td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td colspan="1">&nbsp;&nbsp;&nbsp;Dusun      
                        <input type="text" name="dusun_tujuan" id="dusun_tujuan" class="textinputtiga" placeholder="Dusun"/></td>
                    <td>RT&nbsp;&nbsp;&nbsp;
                        <input type="text" name="rt_tujuan" id="rt_tujuan" class="textinputdua" placeholder="Angka" /></td>
                    <td>RW&nbsp;&nbsp;&nbsp;
                        <input type="text" name="rw_tujuan" id="rw_tujuan" class="textinputdua" placeholder="Angka" /></td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td colspan="1">&nbsp;&nbsp;&nbsp;Kec.&nbsp;&nbsp;&nbsp;&nbsp;
                        <input type="text" name="kecamatan_tujuan" id="kecamatan_tujuan" class="textinputtiga" placeholder="Kecamatan"/></td>
                    <td>Kab.
                        <input type="text" name="kabupaten_tujuan" id="kabupaten_tujuan" class="textinputtiga" placeholder="Kabupaten"/></td>
                    <td>Prop.
                        <select name="idpropinsi" id="idpropinsi" class="list">
                            <?php
                            if (isset($propinsi)) {
                                foreach ($propinsi->result() as $data_propinsi) {
                                    echo '<option value="' . $data_propinsi->idpropinsi . '">' . $data_propinsi->propinsi . '</option>';
                                }
                            }
                            ?>
                        </select></td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td colspan="1">&nbsp;&nbsp;Kd. Pos
                        <input type="text" name="kodepos_tujuan" id="kodepos_tujuan" class="textinputtiga" placeholder="Kode pos "/></td>
                    <td colspan="2">Telp.
                        <input type="text" name="telp_tujuan" id="telp_tujuan" class="textinputtiga" placeholder="0274 868772"/></td>
                </tr>
                <tr>
                    <td>Jenis Kepindahan</td>
                    <td colspan="5"><select name="idjenis_pindah" id="idjenis_pindah" class="list">
                            <?php
                            if (isset($jenis_pindah)) {
                                foreach ($jenis_pindah->result() as $data_jenis_pindah) {
                                    echo '<option value="' . $data_jenis_pindah->idjenis_pindah . '">' . $data_jenis_pindah->jenis_pindah . '</option>';
                                }
                            }
                            ?>
                        </select></td>
                </tr>
                <tr>
                    <td>Status KK yang Tidak Pindah</td>
                    <td colspan="3"><select name="statuskk_tinggal" size="1" class="list" id="statuskk_tinggal">
                            <option value="Numpang KK">Numpang KK</option>
                            <option value="Membuat KK Baru">Membuat KK Baru</option>
                            <option value="No KK Tetap">No KK Tetap</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Status KK yang Pindah</td>
                    <td colspan="3"><select name="statuskk_pindah" size="1" class="list" id="statuskk_pindah">
                            <option value="Numpang KK">Numpang KK</option>
                            <option value="Membuat KK Baru">Membuat KK Baru</option>
                            <option value="No KK Tetap">No KK Tetap</option>
                        </select></td>
                </tr>
                <tr>
                    <td>Tanggal Kedatangan</td>
                    <td colspan="5"><input type="text" name="tanggal_pergi" id="tanggal_pergi" class="textinputtiga" placeholder="Tanggal" /></td>
                </tr>
                <tr>
                    <td>Jumlah Keluarga yang Pindah</td>
                    <td><input type="text" name="jumlah_keluargapergi" id="jumlah_keluargapergi" class="textinputdua" placeholder="Angka" />
                        orang</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                </tr>
                <tr>
                    <td>&nbsp;</td>
                    <td width="249"><input type="submit" name="tambah" id="tambah" value="Tambah" class="btn btn-large"/></td>
                  <td width="248">&nbsp;</td>
                    <td>&nbsp;</td>
                </tr>
            </table>

        </form>
    </body>
</html>
